The Impact of ACA in NYC

45 Pages·2013·3.67 MB·English

by  Blayne Cutler

System-Level Change
& Population-Based Approaches
to Improve HIV Outcomes in NYC

Blayne Cutler, MD PhD
Director, HIV Prevention
Bureau of HIV/AIDS Prevention & Control
NYC Department of Health
NYC Continuum of Care, 2010
The U.S. Continuum of Care
MMWR. December 2, 2011 / 60(47);1618-1623

Trends in HIV/AIDS
New York City, 1981–2010
14,000 120,000
Clinical Milestones in the
History of the HIV / AIDS Epidemic Reported Persons Living with
1987:AZT HIV (non-AIDS)
sh 12,000 1988:PCP prophylaxis 100,000
ta 1992:Combination therapy
e
D 1994:ACTG 076: AZT reduces perinatal transmission
dna s 10,000 11999956::PHrAoAteRaTse inhibitors DPeeartshosn tso uN
e 80,000 m
so with AIDS b
n e
gaiD 8,000 New AIDS R fo r
S e
DIA Diagnoses 60,000 rop
/VIH 6,000 P det
w New HIV L
e W
N Diagnoses H
fo re 4,000 RLeivpionrgte wdi tPhe ArsIoDnSs 40,000 A
b
m
u
N
20,000
2,000
0 0
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
8 8 8 8 8 8 8 8 8 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 1
9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 0
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2
* *
Calendar Year
CDC AIDS case
definition (23 OIs) NYS HIV reporting HIV surveillance
PCFPir,s Kt Sca rseepso rotfe d AIDS case implemented AIDS case NYS expands (cid:144) law takes effect inecxidpeanncdes stuor ivnecilluladnec e
from NYC, LA mreapnodratitnegd First commercial EIA, definition AIDS reporting
AIDS enters the by NYS HIV identified as sscurpepelny inbgeg oinf sU S blood e<xp20a0n,d 2e6d O(CIsD)4 to include HIV
nomenclature causative agent
As reported to NYC DOHMH by September 30, 2011. PLWHA, Persons living with HIV/AIDS.
Data on deaths outside New York City are incomplete.

Core Cascade Approaches in NYC
Policy/System
Level Change
Maximize
Enhanced use of
technological
registry data

approaches
Core Cascade Approaches in NYC
• Shift context through law/policy—NYS Mandated Offer (2010); Institutional Quality Indicators
• Deploy/optimize new technologies--support screening tests that minimize the window period (4th gen EIA)
• Normalize HIV screening for NYC resident and providers through social marketing
Test
• Community Mobilization—Include/engage all partners to play their role (Jurisdictional Scale Up)
• Maximize evidence-based strategies (navigation, partner services) through contracts and DOH FSU
• Train designated navigators on linkage models that work (ARTAS)
• Drive programmatic change contractually—ensure that desired actions are discreet payment points
Link
• ? Reward participant for linkage (HPTN 065)
• Improve ‘relay’ between testing and care agencies (linkage navigators begin MCM intake).
• Deploy effective medical case management with optimized supports (Care Coordination)
• Use contracting process to support co-localization of services (substance use; mental health)
Retain
• Optimize collaboration between clinic and DOH to find out of care individuals (FSU, registry)

• Train providers on new DHHS guidelines.
• Deploy multi-tier treatment adherence approaches that ‘graduate’ toward self-sufficiency
Adhere/ • Provide ‘feedback’ data to individual sites for CQI: (‘Care Continuum Dashboards’)

Suppress
Shifting the Context by Changing the Law

Chapter 308: Laws of 2010

MANDATORY OFFER of HIV test
to all persons 13-64 most
healthcare settings

Simplified consent
Documented oral consent for
tests that process in < 60 min
General medical consent ok
Consent is now durable

Simplified lab ordering

Requires active linkage to care
Chapter 308 of the Laws of 2010

•LINKAGE:

“With the consent of the subjec t of a test indicating evidence
of HIV infection or, if the subject lacks capacity to consent,
with the consent of the person authorized pursuant to law to
consent to health care for the subject, the person who
ordered the performance of the HIV related test, or such
person's representative, shall provide or arrange with a
health care provider for an appointment for follow-up
medical care for HIV for such subject.”

•USE OF REGISTRY DATA
February 2012 regulations expanded use of registry data to
allow limited communication on individual patients between
HD and provider of last record (‘follow-up needed’).
NYS Testing Law: Early Impact
Laboratory Reported HIV Testing
13 Month Before and After NYS Law of 2010
(n=215)

Total Tests 9/09-9/10 Total Tests 10/10-10/11

% Change
(Pre 2010 (Post 2010
HIV Testing Law) HIV Testing Law)
Conventional HIV Screening Tests
(Labs=98) 2,023,968 2,198,390 9%
Rapid HIV Screening Tests (Labs=138) 294,764 322,881 9.5%
Total (Number of Labs = 215) 2,324,914 2,531,253 9%
NYS Department of Health, Laboratory Survey on HIV Testing Practices, 2009-2011.